ACLS Acute Coronary Syndrome

Prehospital Setting: You have been called to the home of a 67-year-old male who is complaining oftightness in his chest that began while he was resting and watching television. He reports that he tookthree nitroglycerin tablets sublingually without any relief. His history includes angina, congestive heartfailure and hypertension. When asked about his compliance with medications, he admits to "only takingthem when he remembers to." He also states that over the past couple of nights he has been sleeping witha lot of pillows propping him up because the shortness of breath "is too much if I lay flat." As time moveson, he becomes very agitated and states it is getting "harder to breathe."

Emergency Department Setting: You are the triage nurse at a local emergency room when a 67-year-oldmale walks into the lobby and is complaining of tightness in his chest. He states the discomfort startedwhile he was resting and watching TV at home.

He reports that he took three nitroglycerin tablets sublingually without any relief. His history includesangina, congestive heart failure and hypertension. When asked about his compliance with medications, headmits to "only taking them when he remembers to." He also states that over the past couple of nights hehas been sleeping with a lot of pillows propping him up because the shortness of breath "is too much if Ilay flat." As time moves on, he becomes very agitated and states it is getting "harder to breathe."

This SCE consists of seven states that automatically and manually transition. With manual transitions,instructors should advance to the applicable state when appropriate interventions are performed.

In State 1 Chest Pain, the patient presents with a HR in the 70s, BP in the 110s/70s, RR in the upperteens and SpO2 in the 90s on room air. The patient's lungs are clear and equal bilaterally, the cardiacrhythm is sinus with mild myocardial ischemia. The patient is alert and oriented to person, place andtime. The patient complains of his chest being tight. The learner is expected to place the patient on 4LPMof oxygen via nasal cannula before transitioning to next state.If the time in this state is greater than 180seconds, the state automatically progresses to State 2 Chest Pain Increases.

In State 2 Chest Pain Increases, the patient's pain increases with a HR in the 70s to 80s, BP in the110s/70s, RR in the teens to 20s and SpO2 in the 90s on oxygen by nasal cannula at 4 LPM. Otherclinical findings include a cardiac rhythm of sinus with ST elevations. The patient states "I can't breathe."

ACLS Acute Coronary Syndrome Page 1

Mark Tuttle, NREMTP, BS METI, and Thomas J. Doyle, MSN, RN, METI - Sarasota, FL, 2009 and reviewed by Richard Low II NREMT-P, BA,and Jerry Andrews CCEMT-P, FP-C, RN METI-Sarasota, FL 2011 ACLS Acute Coronary SyndromeIf the time in this state is greater than 180 seconds, the scenario automatically progresses to State 3 ChestPain Without Relief. If 300 mL or more of crystalloids are infused, manually transition to State 5 AcuteMyocardial Infarction. The learner is expected to note the ST wave elevation on the monitor and obtaina 12 lead ECG and continue with treatment. The 12 lead shows ST elevation in leads II, III and AVF.

In State 3 Chest Pain Without Relief, the patient's condition worsens with a HR in the 80s to 90s, BP inthe 70s/40s, RR in the 30s and SpO2 in the 90s on oxygen by nasal cannula at 4 LPM. The patient alsohas a cardiac rhythm of sinus with ST elevations. The patient is alert, oriented to person and place andextremely anxious. The patient states, "My chest is tight!" If the time in this state is greater than 180seconds, the scenario automatically progresses to State 4 Low Blood Pressure. If 300 mL or more ofcrystalloids are infused, manually transition to State 5 Acute Myocardial Infarction.

In State 4 Low Blood Pressure, the patient's condition continues to deteriorate with a HR in the 110s, BPin the 60s/40s to 50s, RR in the 30s and SpO2 undetectable. Lungs now have crackles throughout andpatient is mumbling. If 300 mL or more of crystalloids are infused, manually transition to State 5 AcuteMyocardial Infarction. If time in this state is greater than 300 seconds, the SCE automaticallyprogresses to State 6 Premature Ventricular Contractions. The learner is expected to respondappropriately to the falling blood pressure.

In State 5 Acute Myocardial Infarction, the patient's condition stabilizes with a HR in the 100s, BP inthe 100s/50s and a RR in the 20s. Cardiac rhythm is sinus with ST elevations and lung sounds aredimished. The learners should be preparing the patient for the cardiac catheterization lab or to beginThrombolytic therapy. This state is a possible endpoint of the SCE.

In State 6 Premature Ventricular Contractions, the patient's condition continues to deteriorate with aHR in the 110s-130s, BP in the 50s-70s/30s-50s and RR in the 30-40s. Lung sounds are crackles andother clinical findings include cyanosis of the fingertips and toes. The learner is expected to recognize thepresence of cyanosis and PVCs and respond appropriately. If the learner fails to intervene appropriately,manually transition to State 7 Death. If the learner responds appropriately, this would be the end of theSCE. If the learner reaches this state, it is recommended to repeat the simulation until a positive outcomeoccurs.

In State 7 Death, the patient's condition deteriorates to ventricular fibrillation. Other clinical findingsinclude absent breath sounds and cyanosis is present. The learner is expected to begin CPR. If the learnergets to this state, it is recommended to repeat the simulation until a positive outcome occurs.

Code Status: Full Code

Social/Family History: Smokes two packs of cigarettes a day

Secondary Assessment: Weight is 100 kg, height is 5'7"; jugular vein distention (JVD) at a 45-degreeangle. The lungs have bibasilar crackles and poor air exchange. The abdomen is soft with no pain onpalpation, the lower extremities have pitting pedal edema, and pedal pulses are present bilaterally. Theupper extremities have equal and strong pulses

Handoff Report

The learner is expected to give a report to the receiving facility that includes patient history, treatmentadministered in the field, the patient's response to interventions and status upon arrival. This report shouldbe given at the conclusion of the SCE.

State 6 Premature Ventricular Contractions:

Describe the pathophysiology of acute myocardial infarction (AMI).

What are modifiable and non-modifiable risk factors for AMI?ACLS Acute Coronary Syndrome Page 4Mark Tuttle, NREMTP, BS METI, and Thomas J. Doyle, MSN, RN, METI - Sarasota, FL, 2009 and reviewed by Richard Low II NREMT-P, BA,and Jerry Andrews CCEMT-P, FP-C, RN METI-Sarasota, FL 2011 ACLS Acute Coronary SyndromeWhat assessments should be performed for a patient with AMI?How can the learner determine what type of oxygen device is needed for this patient?What other means can the learner use if there is no pulse oximeter available?What assessment information would the learner be looking for that would indicate treatment is effective?How does stress affect AMI?Identify three priority-teaching points related to health promotion for the patient with AMI.

This SCE was created with the patient Earl Purtell, and only this patient can be used. The physiologicalvalues documented indicate appropriate and timely interventions. Differences will be encountered whencare is not appropriate or timely.

If using the Muse platform, don't hit Run until you are ready to start the scenario. If using the HPS6platform, open the patient and scenario directory. Do not open the scenario until you are ready to start thesimulated clinical experience.

Where appropriate, do not provide information unless specifically asked by the learner. In addition,ancillary study results (e.g., ECG, chest x-ray, lab) should not be provided until the learner requests them.

If the patient becomes unconscious in the SCE, remember the patient stops speaking.

It is important to moulage the simulator to enhance the fidelity, or realism, of the simulated clinicalexperience. For this patient, dress the simulator in casual clothing and place the simulator in a sittingposition.

For simulators without the diaphoresis feature, spray the face and other appropriate body areas withwater.

For simulators without the cyanosis feature, use a thin coating of mortician's wax or petroleum jelly as abase, then apply moulage paints or ordinary cosmetics (e.g., blue eyeshadow) to the lips and nail beds asindicated.

When the learner initiates cardiac monitoring, the tracing and heart rate appear on a real ECG monitor forthose simulators with this feature. For simulators without ECG monitoring, have the learner apply ECGelectrodes to the mannequin and attach the leads. Once all 3 or 5 leads are in place, reveal the TouchProor Waveform display ECG tracing.

Place a code cart either outside of the room or away from the patient area in the room to allow thesecondary nurse to retrieve it and bring it to the bedside, if needed. Have a code cart and either anautomated external defibrillator or a defibrillator with the code cart.

For simulators without the jugular venous distention or trismus feature, the facilitator should verbalize thepresence of these conditions to learners as approprate.

Simulation center personnel should play the following roles:

Healthcare providerEMTsParamedics

Make a patient chart with the appropriate written order forms, MARs, diagnostic results, etc. for learnersto utilize. The chart should include the specific patient identification information.

Have the learners roleplay inter-professional communication by reporting the patient's response tointerventions. If the data presented is disorganized or missing vital components, have the healthcareprovider become inappropriate in response. Emphasize the importance of data organization andcompleteness when communicating.

When learners apply and/or titrate oxygen, the facilitator should open the Oxygen Intervention Option orTreatment Scenario and choose the appropriate flow rate. If using the HPS, no software command isnecessary when real oxygen is applied.

When learners provide pharmaceutical interventions, the facilitator should open the MedicationIntervention Option or Treatment Scenario and choose the appropriate medication. If using the drugrecognition feature of the HPS, no software command is necessary when a drug is administered using thatsystem.

When learners provide IV fluid interventions, the facilitator should open the Intervention Option orTreatment Scenario and choose the appropriate fluid and volume to be administered.

Debriefing and instruction after the scenario are critical. Learners and instructors may wish to view avideotape of the scenario afterward for instructional and debriefing purposes.

Debriefing Points

The facilitator should begin by introducing the process of debriefing:

Introduction: Discuss faculty role as a facilitator, expectations, confidentiality, safe environment fordiscussionPersonal Reactions: Allow learners to recognize and release emotions, explore learner reactionsDiscussion of Events: Analyze what happened during the SCE, using video playback if availableSummary: Review what went well and what did not, identify areas for improvement and evaluate theexperience

Questions to be asked during debriefing:

What was the experience like for you?What happened and why?What did you do and was it effective?Discuss your interventions (technical and non-technical). Were they performed appropriately and in atimely manner?How did you decide on your priorities for care and what would you change?How did patient safety concerns influence your care? What did you overlook?In what ways did you personalize your care (recognition of culture, concerns, anxiety) for this patient andfamily members?Discuss your teamwork. How did you communicate and collaborate? What worked, what didn't work andwhat you will do differently next time?What are you going to take away from this experience?

State 1 Chest Pain Begins:

What is causing the patient to have chest pain?

Plaque has ruptured in a coronary artery. The plaque releases its contents into the bloodstream resultingin platelet aggregation and thrombus development within the artery.

State 2 Chest Pain Increases:

What is the reason for the patient's chest pain to be increasing despite the care being delivered?If the thrombus partially occludes a coronary vessel, the patient may experience unstable angina. But if ittotally occludes the vessel, an AMI is likely.

State 3 Chest Pain Without Relief:

Why can't this patient get relief, even if the correct treatment is being performed?A myocardial infarction may compromise the function of the heart; therefore, the pump is damagedcausing the patient to have heart failure.

State 4 Low Blood Pressure:

What is causing this patient's blood pressure to continue to fall?

Inadequate cerebral perfusion is causing the blood pressure to fall, which may lead to cardiogenic shock.If this continues without proper treatment, the patient can go into cardiac arrest.

State 5 Acute Myocardial Infarction:

Why is the patient having an AMI?

The occlusion of the coronary artery is interrupting the blood flow to the heart causing ischemia to theheart cells. The myocardium is being deprived of oxygen.

State 6 Premature Ventricular Contractions:

Why is the patient having PVCs?

Because a part of the heart is damaged, the conduction in that area is functioning slower than theconduction in the healthy portions of the heart. This difference in electrical conduction causesarrhythmias.

State 7 Death:

Why do you think the patient went into cardiac arrest?

The prognosis for patients with myocardial infarction varies greatly, depending on the patient, thecondition itself and the given treatment. The outcome can be traced back to the learner.